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    SOAP Note

    Uploaded by

    Saad Abdullah
    The patient is on post-op day 1 following surgery for small bowel obstruction. The patient reports feeling well with abdominal discomfort only with movement. Vitals and labs are stable. The surgical incision is healing well with no complications. The plan is to advance the diet to clear liquids once flatus occurs, continue IV fluids and monitoring, encourage ambulation, and use blood thinners to prevent blood clots.

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    SOAP Note

    Uploaded by

    Saad Abdullah
    692 views1 page
    The patient is on post-op day 1 following surgery for small bowel obstruction. The patient reports feeling well with abdominal discomfort only with movement. Vitals and labs are stable. The surgical incision is healing well with no complications. The plan is to advance the diet to clear liquids once flatus occurs, continue IV fluids and monitoring, encourage ambulation, and use blood thinners to prevent blood clots.

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    How to write a medical SOAP note for the wards.

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    The patient is on post-op day 1 following surgery for small bowel obstruction. The patient reports feeling well with abdominal discomfort only with movement. Vitals and labs are stable. The surgical incision is healing well with no complications. The plan is to advance the diet to clear liquids once flatus occurs, continue IV fluids and monitoring, encourage ambulation, and use blood thinners to prevent blood clots.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    692 views1 page

    SOAP Note

    Uploaded by

    Saad Abdullah
    The patient is on post-op day 1 following surgery for small bowel obstruction. The patient reports feeling well with abdominal discomfort only with movement. Vitals and labs are stable. The surgical incision is healing well with no complications. The plan is to advance the diet to clear liquids once flatus occurs, continue IV fluids and monitoring, encourage ambulation, and use blood thinners to prevent blood clots.

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    Post-Surgery Follow-up SOAP note

    S: Post-op day number 1. Feeling well with no abdominal pain when laying in bed. Notes
    improvement in abdominal distension. Some discomfort with movement. Has been up to use the
    bathroom otherwise remains in bed. Remains NPO. No flatulence or bowel movement since
    surgery.
    O:
    Vitals- Tmax: 99.8, BP- 128/82, P- 82, R-18
    I/O- 3000ml NS IV / 200ml out via foley, 800ml on own, in past 24 hours
    General- laying in bed, appears comfortable
    Skin- Surgical incision margins have minimal erythema and are well approximated with
    staples, no dehiscence, no drainage. No signs of hematoma or seroma formation. No
    jaundice
    Abdomen- mild distension, minimal diffuse tenderness, bowel sounds are active.
    Lungs- CTABL
    CV- RRR, no murmurs or gallops.
    AM labs: CBC: WBC 12,000, trending downward; Electrolytes: normal; BUN 16;
    creatinie 1.1.
    A: Small bowel obstruction with resection and lysis of adhesions. Post-op day #1.
    P: Will continue to monitor patient. Will begin to advance diet to clear liquids when patient
    experiences flatus. Continue maintenance fluids at a rate of 125ml/hour NS. Continue to monitor
    CBC, electrolytes, BUN, and creatinine daily. Encourage ambulation and use of the incentive
    spirometer. Continue low molecular weight heparin for DVT prophylaxis.

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